Medication Safety

C4I Medication Safety Subgroup

A medication error has been defined by the National Coordinating Council for Medication Error and Prevention as “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including: prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.”

Thousands of deaths nationwide are caused by medication errors and the resulting costs are in the billions. At John Dempsey Hospital, prevention of medication errors is a high priority in reaching the goal of safest hospital in Connecticut. A number of strategies have been put in place to eliminate medication errors.

Following Guidelines

Founded in 1994, the Institute for Safe Medicine Practice provides safety guidelines for hospitals nationwide. A nonprofit healthcare agency comprised of pharmacists, nurses, and physicians, the organization, the organization is dedicated to learning about medication errors, understanding their system-based causes, and disseminating practical recommendations that can help healthcare providers, consumers, and the pharmaceutical industry prevent errors.

Using Technology

Computerized Physician Order Entry is a powerful tool that integrates the automated entry of physician orders with the lab, radiology and pharmacy systems. It brings treatment to patients in a more timely and safe manner. Physicians’ orders are automatically checked for a variety of contraindications, including food, drug, and environmental allergies, duplicate ingredients and therapy, and minimum/maximum dose checking. The system provides physicians the safest method of ordering treatments.

Automated Dispensing Machines are drug storage devices or cabinets that electronically dispense medications in a controlled manner and also track medication use. The machine’s primary advantage is that it allows nurses to obtain medications at the point of use. The system requires user identifiers and passwords. Internal electronic devices track nurses accessing the system, the patients using the medications, and provide usage data to the hospital's financial office for billing purposes.

MAK - Medication Administration Checking is a verification system for healthcare professional administering medication.
It checks for the:

• Right Person
• Right Medicine
• Right Time
• Right Dose
• Right Route (oral, topical, nasal, etc.)

Smart Infusion Pumps use calculation software to identify and correct pump-programming areas. The incorrect programming of IV pumps is one of the most common types of medication error and can result in serious adverse events. There is little ability to correct the error before drugs reach the patient. With smart pumps, standard concentrations and upper and lower dose limits can be pre-programmed. The pump alerts nursing staff if programming is outside of safe limits, and prevents the administration of doses that are considered to be unsafe.

Operations/Standards

The Department of Pharmacy implemented changes in operations and standards to reduce medication errors. The C4I Medication subgroup continually looks for ways to improve policies and provide education for staff to reduce medication errors. Standards currently in place include:

High Risk Medications used incorrectly can cause significant harm to patients. At John Dempsey Hospital, access to these medication is limited and order, preparation and administration is standardized. Double checks are also used to avoid administration errors.

Sound-Alike/Look-Alike Drugs are frequently involved in medication errors.
Easily remembered under the acronym of S-A-L-A-D, examples include:

• Celebrex and Celexa
• Quinine and Quinidine
• Zantac and Zyrtec
• Lamictal and Lamisil
• Hespan and Heparin

The following strategies have been put in place to avoid mistakes:

• Use of TALL-man letters, for example: hydroOXYzine and hydrALZAINE
• Avoid brand names
• Avoid storing S-A-L-A-D drugs in close proximity to each other

Abbreviations

Some examples of abbreviations that healthcare professionals should and should not use include:

Medication Reconciliation is one of the target areas of the 2006 National Patient Safety Goals.

The process compares the medications a patient has been taking before admission or entry to a medical setting with the medications about to be dispensed. The purpose of reconciliation is to avoid errors in transcription, omission, duplication of therapy, drug-drug and drug-disease interactions, among others. A medication, as defined by Medication Management Standards, includes any prescription medications, sample medications, herbal remedies, vitamins, nutriceuticals, over-the-counter drugs, vaccines, and diagnostic and contrast agents.

Chair, C4I Medication Safety Subgroup

Philip Bunick, R.Ph., M.H.A.